NSG 223 MEDICAL-SURGICAL NURSING
II HESI FINAL EXAM QUESTIONS AND
ANSWERS
1. A patient with a T4 spinal cord injury reports a sudden, pounding headache and nasal
congestion. The nurse notes a blood pressure of 192/104 mmHg and diaphoresis above the
level of injury. Which action should the nurse perform first?
A. Administer the prescribed PRN dose of hydralazine.
B. Perform a digital rectal exam to assess for fecal impaction.
C. Check the patient’s urinary catheter for kinks or obstruction.
D. Elevate the head of the bed to a high-Fowler’s position.
Answer: D
Conceptual Explanation: The symptoms describe autonomic dysreflexia, a medical
emergency. The priority nursing action is to sit the patient up (high-Fowler’s) to help lower
blood pressure via orthostatic changes before identifying and removing the triggering
stimulus.
,2. An adult client is admitted with partial and full-thickness burns to the entire left arm, the
anterior trunk, and the front of the left leg. Using the Rule of Nines, what is the estimated
Total Body Surface Area (TBSA) burned?
A. 36%
B. 27%
C. 45%
D. 18%
Answer: A
Conceptual Explanation: According to the Rule of Nines: Left arm (9%) + Anterior trunk
(18%) + Anterior left leg (9%) = 36%.
3. A client’s arterial blood gas (ABG) results are: pH 7.31, PaCO2 50 mmHg, and HCO3 29
mEq/L. Which interpretation is correct?
A. Partially compensated respiratory acidosis
B. Uncompensated respiratory acidosis
C. Fully compensated metabolic alkalosis
D. Partially compensated metabolic acidosis
Answer: A
, Conceptual Explanation: The pH is low (acidosis), PaCO2 is high (respiratory cause), and
the HCO3 is high (compensatory mechanism), but the pH is not yet within the normal
range, indicating partial compensation.
4. A client with Type 1 Diabetes Mellitus is admitted with Diabetic Ketoacidosis (DKA). The
nurse initiates an insulin drip. Which laboratory value is most critical for the nurse to monitor
frequently during the first few hours of treatment?
A. Serum potassium
B. Blood Urea Nitrogen (BUN)
C. Serum sodium
D. Hemoglobin A1c
Answer: A
Conceptual Explanation: As insulin shifts glucose into cells, potassium also moves into the
intracellular space, which can lead to rapid hypokalemia and life-threatening dysrhythmias.
5. Which assessment finding should the nurse recognize as the hallmark sign of cardiac
tamponade?
A. Widening pulse pressure and bradycardia
B. Inspiratory crackles and a frothy cough
C. Muffled heart sounds and jugular venous distention
D. Flattened neck veins and hypotension
II HESI FINAL EXAM QUESTIONS AND
ANSWERS
1. A patient with a T4 spinal cord injury reports a sudden, pounding headache and nasal
congestion. The nurse notes a blood pressure of 192/104 mmHg and diaphoresis above the
level of injury. Which action should the nurse perform first?
A. Administer the prescribed PRN dose of hydralazine.
B. Perform a digital rectal exam to assess for fecal impaction.
C. Check the patient’s urinary catheter for kinks or obstruction.
D. Elevate the head of the bed to a high-Fowler’s position.
Answer: D
Conceptual Explanation: The symptoms describe autonomic dysreflexia, a medical
emergency. The priority nursing action is to sit the patient up (high-Fowler’s) to help lower
blood pressure via orthostatic changes before identifying and removing the triggering
stimulus.
,2. An adult client is admitted with partial and full-thickness burns to the entire left arm, the
anterior trunk, and the front of the left leg. Using the Rule of Nines, what is the estimated
Total Body Surface Area (TBSA) burned?
A. 36%
B. 27%
C. 45%
D. 18%
Answer: A
Conceptual Explanation: According to the Rule of Nines: Left arm (9%) + Anterior trunk
(18%) + Anterior left leg (9%) = 36%.
3. A client’s arterial blood gas (ABG) results are: pH 7.31, PaCO2 50 mmHg, and HCO3 29
mEq/L. Which interpretation is correct?
A. Partially compensated respiratory acidosis
B. Uncompensated respiratory acidosis
C. Fully compensated metabolic alkalosis
D. Partially compensated metabolic acidosis
Answer: A
, Conceptual Explanation: The pH is low (acidosis), PaCO2 is high (respiratory cause), and
the HCO3 is high (compensatory mechanism), but the pH is not yet within the normal
range, indicating partial compensation.
4. A client with Type 1 Diabetes Mellitus is admitted with Diabetic Ketoacidosis (DKA). The
nurse initiates an insulin drip. Which laboratory value is most critical for the nurse to monitor
frequently during the first few hours of treatment?
A. Serum potassium
B. Blood Urea Nitrogen (BUN)
C. Serum sodium
D. Hemoglobin A1c
Answer: A
Conceptual Explanation: As insulin shifts glucose into cells, potassium also moves into the
intracellular space, which can lead to rapid hypokalemia and life-threatening dysrhythmias.
5. Which assessment finding should the nurse recognize as the hallmark sign of cardiac
tamponade?
A. Widening pulse pressure and bradycardia
B. Inspiratory crackles and a frothy cough
C. Muffled heart sounds and jugular venous distention
D. Flattened neck veins and hypotension
